Action Points

Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

Utilization of a comprehensive maternal hemorrhage protocol significantly reduced the number of blood products, and also reduced the severity of maternal hemorrhage and the rate of puerperal hysterectomy.

The packed red blood cell use in this setting dropped a significant 22% across a group of hospitals after adopting the protocol, Larry Shields, MD, of Marian Regional Medical Center in Santa Maria, Calif., and colleagues reported.

Peripartum hysterectomy fell 45% from 20 cases in the month when the program became mandatory to 11 in the month after the program was in place in the analysis presented here at the Society for Maternal-Fetal Medicine meeting.

"These data support the recommendation that all hospitals should implement a standardized protocol for the treatment of maternal hemorrhage," Shields told attendees.

A standardized approach with an opportunity for training and drills may help overcome infrequent experience with severe events, he explained.

His group examined outcomes at hospitals in the Dignity Health system, which covers about one in every eight births in the state of California, as it implemented such a program.

All hospitals had to have an obstetrical hemorrhage cart as a single location for all emergency supplies, including a protocol flow diagram, phone list, diagrams for compression sutures, IV fluids, and Bakri balloon.

The protocol broke down care into stages with an escalating number of people assigned to a woman as she moved through the levels:

Stage 0 was normal, with routine postpartum care

Stage 1 was more than expected bleeding, with standardized usual care

Stage 2 was a requirement for more than two uterotonic agents or not responding to usual care, at which point the anesthesiologist and obstetrician were required to go to the bedside for evaluation and the woman was tested for disseminated intravascular coagulation problems

Stage 3 was the most severe with blood loss over 1,500 cc or abnormal vital signs, with the assumption that the patient was to be transfused with blood products in a specified ratio

Adherence to the protocols, based on monthly audits at each hospital, was 54% in the baseline of November-December 2011 when it was decided that it would be mandatory for across the hospital system.

When compared with May-June 2012 when adherence reached around 70%, blood product use was down substantially, despite recommendation for early transfusion.

The system used 31% fewer fresh frozen platelet units, 43% fewer units of platelets, and 58% less cryoprecipitate along with the reduced use of packed red blood cells (all P<0.05).

Shields suggested two reasons for these changes.

"Number one is early attention to the patient and keeping track of what's going on rather than the patient presenting with really catastrophic bleeding, so the escalation of stages is really important," he told attendees.

"Second, clearly the transfusion with a prescribed ratio of packed cells to fresh frozen plasma makes a huge difference. You're able to stop their bleeding sooner rather than to keep giving another pack of red cells, another pack of red cells, and it just draining out."

Only one patient was transfused four or more units of packed red blood cells, compared with eight at baseline for an 88% drop.

The number of patients correctly escalated to higher stages rose 25% over the period from the protocol becoming mandatory to follow-up, from 101 to 126.

Those results were largely sustained through September-October 2012, by which time adherence had risen to over 75%. The one exception was a 60% increase in fresh frozen plasma use over baseline, which Shields said was consistent with the desired transfusion ratios.

Limitations included lack of access to individual chart data and that physicians may have gotten a good outcome despite not following the protocol.

The study was supported by Dignity Health.

Shields reported working at a hospital in the Dignity Health system.

Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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